Insurance Information

Medical insurance

Subscriber name

Date of birth

Date Format: MM slash DD slash YYYY

List 4 SS#

ID

Relation to Subscriber

Vision insurance

I authorized and consent to the examination and treatment of the above patient. I certify that the information above is correct. I authorize the doctor to release any information needed to process my insurance claims and I assign payment to the provider of any benefits. I am responsible for any copays at the time of the visit and I will forward payment for any expenses applied to my deductible once my insurance company is billed. Full payment is due for out of pocket contact / glasses expenses before they can be ordered.